Provider Demographics
NPI:1104117241
Name:DAISY DENTAL P.C.
Entity type:Organization
Organization Name:DAISY DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:940-497-6453
Mailing Address - Street 1:3970 FM 2181
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HICKORY CREEK
Mailing Address - State:TX
Mailing Address - Zip Code:75065-4249
Mailing Address - Country:US
Mailing Address - Phone:940-497-6453
Mailing Address - Fax:
Practice Address - Street 1:3970 FM 2181
Practice Address - Street 2:SUITE 200
Practice Address - City:HICKORY CREEK
Practice Address - State:TX
Practice Address - Zip Code:75065-4249
Practice Address - Country:US
Practice Address - Phone:972-999-3580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-24
Last Update Date:2011-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22585261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1900193-03OtherMEDICAID PROVIDER
TX2208027-01Medicaid